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Intermittent Explosive Disorder
DSM-II In DSM-II, this disorder is called Explosive personality This behavior pattern is characterized by gross outbursts of rage or of verbal or physical aggressiveness. These outbursts are strikingly different from the patent's usual behavior, and he may be regretful and repentant for them. These patients are generally considered excitable, aggressive and over-responsive to environmental pressures. It is the intensity of the outbursts and the individual's inability to control them which distinguishes this group. Cases diagnosed as "aggressive personality" are classified here. If the patient is amnesic for the outbursts, the diagnosis of Hysterical neurosis, Non-psychotic OBS with epilepsy or Psychosis with epilepsy should be considered. DSM-III Diagnostic Criteria A'''. Several discrete episodes of loss of control of aggressive impulses resulting in serious assault or destruction of property. '''B. Behavior that is grossly out of proportion to any precipitating psychosocial stressor. C'''. Absence of signs of generalized impulsivity or aggressiveness between episodes. '''D. Not due to Schizophrenia, Antisocial Personality Disorder, or Conduct Disorder. Differential Diagnosis Underlying physical disorder An underlying physical disorder, such as a brain tumor or epilepsy, may in rare cases cause this syndrome. In such instances the diagnosis Intermittent Explosive Disorder should be recorded, as well as the physical disorder. Antisocial Personality Disorder In Antisocial Personality Disorder, outbursts of aggressiveness are common, but aggressiveness and impulsivity are also present between the outbursts. Dissociative Disorders In Dissociative Disorder any loss of control that occurs invariably follows a major stressful event, whereas in this disorder there is usually only a minor or no precipitating event. In any case, if the disturbance meets the criteria for Intermittent Explosive Disorder, this precludes a diagnosis of a Dissociative Disorder. Paranoid Disorders and Schizophrenia In Paranoid Disorder or Schizophrenia, Catatonic Type, there may be outbursts of violent behavior in response to delusions or hallucinations. DSM-IV Diagnostic Criteria A'''. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. '''B. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors. C'''. The aggressive episodes are not better accounted for by another mental disorder (e.g., Antisocial Personality Disorder, Borderline Personality Disorder, a Psychotic Disorder, a Manic Episode, Conduct Disorder, or Attention-Deficit/Hyperactivity Disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer's disease). '''Differential Diagnosis Delirium, Dementia, and Personality Change Due to a General Medical Condition Aggressive behavior can occur in the context of many other mental disorder. A diagnosis of Intermittent Explosive Disorder should be considered only after all other disorders that are associated with aggressive impulses or behavior have been ruled out. If the aggressive behavior occurs exclusively during the course of a delirium, a diagnosis of Intermittent Explosive Disorder is not given. Similarly, when the behavior develops as part of a dementia, a diagnosis of Intermittent Explosive Disorder is not made and the appropriate diagnosis is dementia with specifier With Behavioral Disturbance. Intermittent Explosive Disorder should be distinguished from Personality Change Due to a General Medical Condition, Aggressive Type, which is diagnosed when the pattern of aggressive episodes is judged to be due to the direct physiological effects of a diagnosable general medical condition (e.g., an individual who has suffered brain injury from an automobile accident and subsequently manifests a change in personality characterized by aggressive outbursts). A careful history and a thorough neurological evaluation are helpful in making the determination. Note that nonspecific abnormalities on neurological examination (e.g., "soft signs") and nonspecific EEG changes are compatible with a diagnosis of Intermittent Explosive Disorder and only preempt the diagnosis if they are indicative of a diagnosable general medical condition. Substance Intoxication and Substance Withdrawal Aggressive outbursts may also occur in association with Substance Intoxication or Substance Withdrawal, particularly associated with alcohol, phencyclidine, cocaine and other stimulants, barbiturates, and inhalants. The clinician should inquire carefully about the nature and extent of substance use, and a blood or urine drug screen may be informative. Oppositional Defiant Disorder, Conduct Disorder, Antisocial Personality Disorder, Borderline Personality Disorder, a Manic Episode, and Schizophrenia Intermittent Explosive Disorder should be distinguished from the aggressive or erratic behavior that can occur in Oppositional Defiant Disorder, Conduct Disorder, Antisocial Personality Disorder, Borderline Personality Disorder, a Manic Episode, and Schizophrenia. If the aggressive behavior is better accounted for as a diagnostic or associated feature of another mental disorder, a separate diagnosis of Intermittent Explosive Disorder is not given. Purposeful behavior and malingering Aggressive behavior may, of course, occur when no mental disorder is present. Purposeful behavior is distinguished from Intermittent Explosive Disorder by the presence of motivation and gain in the aggressive act. In forensic settings, individuals may malinger Intermittent Explosive Disorder to avoid responsibility for their behavior. DSM-5 Diagnostic Criteria A'''. Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following: # Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals. # Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period. '''B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors. C'''. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (e.g., money, power, intimidation). '''D. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or are associated with financial or legal consequences. E'''. Chronological age is at least 6 years (or equivalent developmental level). '''F. The recurrent aggressive outbursts are not better explained by another mental disorder (e.g., major depressive disorder, bipolar disorder, disruptive mood dysregulation disorder, a psychotic disorder, antisocial personality disorder, borderline personality disorder) and are not attributable to another medical condition (e.g., head trauma, Alzheimer's disease) or to the physiological effects of a substance (e.g., a drug of abuse, a medication). For children ages 6-18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis. Note: This diagnosis can be made in addition to the diagnosis of attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum disorder when recurrent impulsive aggressive outbursts are in excess of those usually seen in these disorders and warrant independent clinical attention. Differential Diagnosis A diagnosis of intermittent explosive disorder should not be made when Criterion A1 and/or A2 are only met during an episode of another mental disorder (e.g., major depressive disorder, bipolar disorder, psychotic disorder), or when impulsive aggressive outbursts are attributable to another medical condition or to the physiological effects of a substance or medication. This diagnosis also should not be made, particularly in children and adolescents ages 6-18 years, when the impulsive aggressive outbursts occur in the context of an adjustment disorder. Other examples in which recurrent, problematic, impulsive aggressive outbursts may, or may not, be diagnosed as intermittent explosive disorder include the following. Disruptive mood dysregulation disorder In contrast to intermittent explosive disorder, disruptive mood dysregulation disorder is characterized by a persistently negative mood state (i.e., irritability, anger) most of the day, nearly every day, between impulsive aggressive outbursts. A diagnosis of disruptive mood dysregulation disorder can only be given when the onset of recurrent, problematic, impulsive aggressive outbursts is before age 10 years. Finally, a diagnosis of disruptive mood dysregulation disorder should not be made for the first time after age 18 years. Otherwise, these diagnoses are mutually exclusive. Antisocial personality disorder or borderline personality disorder Individuals with antisocial personality disorder or borderline personality disorder often display recurrent, problematic impulsive aggressive outbursts. However, the level of impulsive aggression in individuals with antisocial personality disorder or borderline personality disorder is lower than that in individuals with intermittent explosive disorder. Delirium, major neurocognitive disorder, and personality change due to another medical condition, aggressive type A diagnosis of intermittent explosive disorder should not be made when aggressive outbursts are judged to result from the physiological effects of another diagnosable medical condition (e.g., brain injury associated with a change in personality characterized by aggressive outbursts; complex partial epilepsy). Nonspecific abnormalities on neurological examination (e.g., "soft signs") and nonspecific electroencephalographic changes are compatible with a diagnosis of intermittent explosive disorder unless there is a diagnosable medical condition that better explains the impulsive aggressive outbursts. Substance intoxication or substance withdrawal A diagnosis of intermittent explosive disorder should not be made when impulsive aggressive outbursts are nearly always associated with intoxication with or withdrawal from substances (e.g., alcohol, phencyclidine, cocaine and other stimulants, barbiturates, inhalants). However, when a sufficient number of impulsive aggressive outbursts also occur in the absence of a substance intoxication or withdrawal, and these warrant independent clinical attention, a diagnosis of intermittent explosive disorder may be given. Attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum disorder Individuals with any of these childhood-onset disorders may exhibit impulsive aggressive outbursts. Individuals with ADHD are typically impulsive and, as a result, may also exhibit impulsive impulsive aggressive outbursts. While individuals with conduct disorder can exhibit impulsive aggressive outbursts, the form of aggression characterized by the diagnostic criteria is proactive and predatory. Aggression in oppositional defiant disorder is typically characterized by temper tantrums and verbal arguments with authority figures, whereas impulsive aggressive outbursts in intermittent explosive disorder are in response to a broader array of provocation and include physical assault. The level of impulsive aggression in individuals with a history of one or more of these disorders has been reported as lower than that in comparable individuals whose symptoms also meet intermittent explosive disorder Criteria A through E. Accordingly, if Criteria A through E are also met, and the impulsive aggressive outbursts warrant independent clinical attention, a diagnosis of intermittent explosive disorder may be given.